Barbara Tempesta

Spontaneous pneumomediastinum: Diagnostic and therapeutic interventions

ObjectivesThe objective of this case series is to review our experience with spontaneous pneumomediastinum, review the available literature, and refine the current clinical approach to this uncommon condition.MethodsThe case notes of all patients admitted to the George Washington University Medical Center with spontaneous pneumomediastinum from April 2005 to June 2008 were retrospectively reviewed, indentifying seventeen patients on whom various data was collected and analyzed.ResultsThe typical patient is a young man. The commonest presenting complaint is chest pain. Odynophagia and subcutaneous emphysema are common. Leucocytosis is uncommon. The need for swallow studies, antibiotics, and prolonged hospitalization is uncommon. Most patients have no recurrences or sequelae on long-term follow-up.ConclusionSpontaneous pneumomediastinum is an uncommon, self-limiting condition. Due to concerns for the integrity of the aero-digestive tract, the finding of spontaneous pneumomediastinum usually results in unnecessary radiological investigations, dietary restriction and antibiotic administration with prolonged hospitalization.

Outpatient management of post-pneumonectomy and post-lobectomy empyema using the vacuum-assisted closure system

PurposeThe conventional management of a post-pneumonectomy (PPE) and post-lobectomy empyema (PLE) necessitates an open window, wound packing, frequent wound debridement, and prolonged hospitalization. We studied the feasibility of outpatient therapy in this patient population using the vacuum-assisted closure (VAC) therapy system.MethodsFrom September 2005 to November 2007, six patients with PPE and PLE with or without a bronchopleural fistula underwent outpatient therapy using a VAC system. After debridement and closure of the bronchial fistula, a VAC system was applied and the patient was discharged. The patient returned for debridement under anesthesia and VAC replacement every 7–10 days. Once the pleural space was cleaned, the residual space was obliterated, and the wound was closed over suction catheters. Of the six patients, two developed recurrent infection after the closure that required repeated VAC dressings and flap closures.ResultsThe outpatient use of the VAC system in patients with PPE and PLE avoided the need for any daily painful dressing changes and significantly decreased the total length of hospitalization and the time to closure of the empyema space, and thus increased the overall patient satisfaction.ConclusionsOur results suggest that outpatient VAC therapy of PPE and PLE is feasible and beneficial.

Novel thoracoscopic approach to posterior mediastinal goiters: report of two cases

Trans-cervical resection of posterior mediastinal goiters is usually very difficult, requiring a high thoracotomy. Until recently, using conventional video-assisted thoracoscopic surgery to resect such tumors has been technically difficult and unsafe. By virtue of 3 dimensional visualization, greater dexterity, and more accurate dissection, the Da Vinci robot, for the first time, enables a completely minimally invasive approach to the posterior superior mediastinum.

Robot-Assisted Thoracoscopic Resection of Intralobar Sequestration

In this paper, we report the first case of a robot-assisted thoracoscopic resection of intralobar sequestration. By virtue of greater dexterity and three-dimensional visualization, the da Vinci robot enables a safer, more precise dissection of sequestered tissue in the face of chronic inflammatory adhesions than conventional video-assisted thoracoscopic surgery does. Thus, in expert hands, such robotic technology is likely to result in less bleeding complications and less conversions to open surgery in cases of sequestration.

Spontaneous cervicothoracolumbar pneumorrhachis, pneumomediastinum and pneumoperitoneum

Introduction:  Pneumorrhachis, or epidural pneumatosis, is a rare entity that is usually traumatic or iatrogenic. Usually, the epidural emphysema is limited to a few vertebral spaces. Less commonly, it is secondary to mediastinal air that tracks into the epidural space. Mediastinal air is usually associated with subcutaneous emphysema, but rarely is it associated with pneumopericardium or pneumoperitoneum. The cause of pneumomediastinum is usually identifiable on history or radiology.

Proposed pathogenesis of Paget–Schroetter disease: impingement of the subclavian vein by a congenitally malformed bony tubercle on the first rib

Aim To study and compare the anatomical and clinical pathology of first ribs in patients with Paget–Schroetter Disease (PSD) with first ribs in patients without the disease. Methods In a case–control study, normal human cadaver first ribs were compared with first ribs from patients with PSD. Ribs, intraoperative videos of transthoracic en bloc surgical resection of the first rib, and preoperative and postoperative dynamic upper extremity venograms were reviewed. Results Fifteen first ribs were from patients with PSD and seven normal first ribs were from human cadavers. In all patients (100%) with PSD there was a bony tubercle that corresponded to the area of the subclavian vein groove in the normal ribs. In all controls (100%), there was a normal subclavian groove without the presence of a tubercle. On preoperative venograms in patients with PSD, the tubercle accounted for an extrinsic protuberance that compressed the subclavian vein (100%). Intraoperatively, the abnormal bony tubercle accounted for the extrinsic compression of the subclavian vein in all (100%) patients with PSD. Venograms of the upper extremity obtained after first rib resection showed the disappearance of the extrinsic compression on the subclavian vein (100%) and a patent subclavian vein with elevation of the arm in all patients. Conclusions A bony tubercle at the site of the subclavian vein groove in patients with PSD causes extrinsic compression of the subclavian vein at rest.

Novel thoracoscopic approach to difficult posterior mediastinal tumors

Thoracoscopic resection is the preferred treatment of posterior mediastinal tumors. However, thoracotomy may be necessary if the tumors are large or adherent; if they are demonstrate invasion or intraspinal growth; or if they are located in the superoposterior mediastinum or posterior costodiaphragmatic angle. We describe a case of a large, adherent posterior costodiaphragmatic mediastinal mass that would have been otherwise difficult to resect thoracoscopically if it were not for the three-dimensional visualization, greater dexterity, and accurate dissection offered by the Da Vinci robot.

Laimer's Diverticulum, A Rare True Diverticulum Inferior to the Cricopharyngeus: Report of a Case and Review of the Literature

Hypopharyngeal esophageal diverticula are rare with the most common type being the Zenker’s diverticulum. This diverticulum arises from Killian’s triangle above the cricopharyngeus muscle; however there are two much rarer hypopharyngeal diverticula distinct from the Zenker’s diverticulum, the Killian-Jamieson diverticulum and the Laimer’s diverticulum. We present a 46 year old male with a hypopharyngeal diverticulum inferior to the cricopharyngeus in the posterior midline consistent with a Laimer’s diverticulum, detail our surgical technique, and review the literature on the diagnosis, etiology, and treatment of this rare phenomenon.

Post-esophagectomy pseudomembranous inflammation of the interposed colon

BACKGROUND Pseudomembranous colitis (PMC) usually is caused by antibiotic-related changes in colonic anaerobic microflora, leading to Clostridium difficile overgrowth and overproduction of toxins. We present the first reported case of PMC affecting the intrathoracic, interposed colon of an esophagectomy patient in the absence of inflammation of the in situ colon. METHODS Case report and review of pertinent English-language literature. CASE REPORT A 47 year-old male developed Clostridium difficile-related colitis after in Ivor-Lewis esophagectomy for carcinoma of the esophagus, and rendered asymptomatic after 10 days of therapy with oral vancomycin. Postoperatively, the patient developed a broncho-esophageal fistula, and was reconstructed with a two-stage colonic esophageal colonic interposition three months after the fistula was closed surgically. On postoperative day nine, the patient developed symptomatic PMC of the interposed colon segment, whereas the in situ colon was spared. Therapy with oral vancomycin for three weeks eradicated the infection. CONCLUSIONS Pseudomembranous colitismay develop in the interposed colon after a esophageal colonic interposition, even absent inflammation of the in situ colon. Previous infection with C. difficile may have increased the risk in this patient.

Fluoroscopic management of a metastatic esophagopleural fistula.

G d d r i d s o 73-year-oldwomanpresentedwithdysphagia to solids12years fter modified radical mastectomy and adjuvant chemoradiation or breast cancer. She had an esophageal stricture which, on bipsy, was diagnosed as metastatic breast cancer.The stricture was nitially stentedendoscopically.Fivedayspost-procedure, shepreentedwith feveranddyspnea.Pneumomediastinumandarightided pleural effusion were noted on CT of the chest (A). A gasrograffin swallow confirmed an esophagopleural fistula (B).